Environmental Scan of MLTSS Quality Requirements in MCO Contracts. Appendix F. Kansas Kancare


  Element     Description/Notes  
State and Lead Agency Kansas Department of Health and Environment (KDHE)
NOTE: Kansas opted to write a very short contract (see 01 Kansas Sunflower Contract for sample). The contract incorporates by reference all of the RFP documents.
Program KanCare
Inception January 2013
Year LTSS Added Per 2012 state legislation, HCBS for individuals with IDD are not to be provided under a managed care system until January 1, 2014. A pilot demonstration program will be developed for this population between January 1, 2013 and January 1, 2014.
Medicaid Authority Seeking a global 1115 waiver.
# Enrolled 26,000 (projected for January 1, 2014)
Group Enrolled
  • Children with autism;
  • Children and adults with DD;
  • People ages 16-64 with PD;
  • Medically fragile children ages 0-22 dependent on intensive medical technology (TA);
  • People ages 16-64 with TBI;
  • People 65 and older who are functionally eligible for NF (FE);
  • Children who are SED.

Per 2012 state legislation, HCBS for individuals with IDD are not to be provided under a managed care system until January 1, 2014. A pilot demonstration program will be developed for this population between January 1, 2013 and January 1, 2014.

  1. MCO Quality Management Infrastructure
a. Staffing requirements for quality oversight/reporting.

MCOs are required to have a full-time QM director who is responsible for quality activities. This person shall have relevant experience in QM for physical and/or behavioral health care quality.

b. Staffing and processes for provider monitoring and associated reporting requirements.

MCOs shall demonstrate that providers are credentialed as prescribed in federal regulations and follow a documented process for credentialing and re-credentialing of providers who have signed contracts or participation agreements with MCOs using the state's Standardized Credentialing Application. MCOs shall establish procedures to ensure that network providers comply with all timely access requirements and be able to provide documentation demonstrating monitoring. MCOs shall regularly monitor providers to ensure compliance and shall take corrective actions if a provider is found to be non-compliant.

c. Staffing and processes for care coordinator monitoring and associated reporting requirements.

MCOs shall be responsible for the management, coordination, and continuity of care for all members and shall develop and maintain policies and procedures to address this responsibility. The MCO shall have systems in place to ensure well-managed care including at a minimum:

  • Management and integration of health care through primary provider/other means.
  • Provision of systems to assure referrals for medically necessary, specialty, secondary and tertiary care and a person or entity formally designated as primarily responsible for coordinating the health care services furnished to the enrollee.
  • Provision of systems to assure provision of care in emergency situations, including an educational process to help assure that members know where and how to obtain medically necessary care in emergency situations.
  • Monitoring coordination of care among PCPs, specialists, behavioral health providers, and long-term care providers.
  • Maintaining performance-based outcomes in NFs for care coordination including case management.
  • Performing age and gender specific preventive health care management services in accordance with current best practices, having mechanisms to assess the quality and appropriateness of services furnished, and provide appropriate referral and scheduling assistance.
  • Monitoring members with ongoing medical or behavioral health conditions.
  • Identifying members using emergency department services inappropriately to assist in scheduling follow-up care with PCPs and/or appropriate specialists to improve continuity of care and establish a medical home.
  • Maintaining and operating a formalized hospital and/or institutional discharge planning program.
  • Coordinating hospital and/or institutional discharge planning that includes post-discharge care, as appropriate.
  • Maintaining an internal tracking system that identifies the current preventive services screening status and pending preventive services screening due dates for each member.

There are also special requirements for care coordination for members with complex needs. The state intends to procure services that promote patient-centered care and improve health outcomes for the entire population, but particularly for high risk, high service utilizes and other high cost individuals with complex needs.

d. IT requirements in support of quality monitoring and reporting.

The MCO shall submit a plan to the state that details how it will use IT to improve coordination and integration of care, promote prevention and wellness, and improve quality through appropriate sharing of clinical and administrative data among providers and to the state.

e. CI investigation processes and associated reporting requirements.

MCOs shall carry out activities that are consistent with state initiatives to reduce CIs.

f. Mechanisms for monitoring receipt of community LTSS and associated reporting requirements.

MCOs shall utilize and comply with all terms of the state's EVV System. The EVV system will be used to monitor the receipt and utilization of HCBS. This system logs the arrival and departure of an individual provider staff person or worker, verifies the identity of the staff person providing the service to the member, and provides immediate notification to the MCO if a provider does not arrive as scheduled.

The MCO shall ensure that the EVV system creates and makes available on at least a daily basis an electronic claims submission file and shall monitor and use information from the EVV system to verify that services are provided as specified in the POC and in accordance with the established schedule. This includes the amount, frequency, duration, and scope of each service and that services are provided by the authorized provider/worker. The EVV system must also identify service gaps, including late and missed visits.

g. Mechanisms for handling complaints/grievances/appeals, and associated reporting requirements.

The MCO is required to provide a toll-free telephone number for members to call who have inquiries, questions, grievances, and etc. This line shall also be used to monitor:

  • Information provided to beneficiaries;
  • Grievances;
  • Timely access;
  • Coordination/continuity;
  • Quality of care.

The data are used to monitor the above topics by obtaining information from the members, resolving issues, identifying and addressing trends. If deficiencies are noted the MCO must perform corrective action until compliance is met.

A grievance may be received by telephone, voice mail, e-mail, written communication or by a person. The MCO is responsible for documenting, investigating and resolving all grievances in a courteous and prompt manner. The MCOs shall establish an internal grievance and appeal process to identify record, investigate, resolve and report grievances. The grievance process must be in full compliance with all applicable state and federal laws and shall not supplant, delay, or hinder the fair hearing/appeal process.

MCOs must provide a system to track and document all grievances. The grievance tracking system shall provide operational and management information at various levels, show resolution, measure and track timeframes, allow referrals to other entities and allow inquiry into multiple fields. MCOs shall also develop a database extract file that can be imported into the state fiscal agent's grievance database.

h. Other.

None specified.

  1. LTSS Performance Measures Requirements
The state has multiple performance measures. Some are targeted for specific 1915(c) HCBS waiver populations including the following:
  • Children with autism;
  • Children and adults with DD;
  • People ages 16-64 with PD;
  • Medically fragile children age 0-22 dependent on intensive medical technology (TA);
  • People ages 16-64 with TBI;
  • People 65 and older who are functionally eligible for NFs (FE);
  • Children who are SED.

Similar HCBS waiver performance measures in the domains of access, eligibility, POC development, choice, health and welfare, financial accountability and customer satisfaction are required for each of the populations. Additionally, LTSS-specific performance measures include the following:

  • Percentage of members reporting their physical health as good within 1 standard deviation of the mean.
  • Percentage of members reporting they are connected to the people who support them the most within 1 standard deviation of the mean.
  • Percentage of members reporting they are doing what they want for their work within 1 standard deviation of the mean.
  • Percentage of adults with an SPMI who report having a place to live that is comfortable for them.
  • Percentage of re-admissions at 30 days, 90 days and 1 year from last discharge from:
    • State MH hospitals, alternatives to state MH hospitals, and Medicaid-funded community hospital psychiatric inpatient programs for children and youth;
    • State MH hospitals and Medicaid-funded community hospital inpatient programs for adults;
    • NFs for MH;
    • Psychiatric residential treatment facilities.
  • Average Length of Stay for youth admitted to psychiatric residential treatment facility will be 100 days or lower.
  • The MCO will ensure providers offer timely initial appointments. 85% of members will be offered an initial appointment within 10 calendar days.
  • The MCO will maintain the following access standards for screening for institutional care:
    • Post-stabilization 1 hour within 1 hour from initial contact to arrival of provider in an ER;
    • Emergent immediate within 1 hour urgent 24 hours from referral.
  • The MCO will ensure that 95% of appeals are resolved as expeditiously as the member's health condition requires.
  1. PIP Requirements
Each MCO must submit new data on at least 2 PIPs annually to the state, though not necessarily 2 new PIPs per year. The PIPs must be approved by the state prior to implementation. The MCOs shall identify HEDIS, NOMS, CMS approved HCBS Waiver Performance Measures and other benchmarks identified by the state and set achievable performance goals for each of its PIPs.
  1. EQRO Requirements
MCOs are required to cooperate and participate in EQRO activities in accordance with state protocols. The EQRO conducts annual, external, independent reviews of the quality outcomes, timeliness of, and access to the services provided by the MCO. MCOs are required to collaborate with the EQRO to develop studies, surveys and other analytic activities to assess the quality of care and services provided to members and to identify opportunities for improvement. MCOs must also work collaboratively with the state and the EQRO to annually measure performance measures. MCOs shall respond to recommendations made by the EQRO within the timeframe established by the EQRO. The purpose of the EQRO is to:
  • Provide the state with an independent assessment of the quality of care delivered to members.
  • Resolve identified problems or contribute to improving the care of all members.
  • Measure MCO compliance with contract requirements.

MCOs are required to provide full co-operation with the EQRO to assure quality and accessibility of health care in the appropriate setting to members including the validation of PIPs and performance measures.

  1. Care Coordination Requirements
a. Assessment tool requirements.

SA: KCPC screening and assessment tool which is based on ASAM criteria.

DD: DD Profile is an assessment tool designed to provide information concerning an individual's functional abilities in 3 areas: adaptive functioning, maladaptive behaviors and health.

FE: Utilizes FE Uniform Assessment Instrument to determine eligibility for FE waiver services.

b. Care coordinator to LTSS member ratio requirement.

None specified.

c. Frequency and nature of LTSS member monitoring.

The MCO is responsible for tracking LOC re-determinations to ensure they are conducted at least annually following the process as provided by the state. Also annual face-to-face reassessments are required.

d. LTSS/acute care coordination requirements.

The state provides funding to local health departments for the provision of health care services to low income individuals. The MCO shall make a reasonable effort to subcontract with any local health care provider receiving funds from Titles V and X of the Social Security Act. Close co-operation with these entities is strongly encouraged. The MCO must have written policies and procedures for assigning each of its members to a PCP/health home.

e. Risk assessment and mitigation requirements.

MCOs shall have programs and processes in place to address the preventive and chronic health care needs of all members. MCOs shall implement processes to assess, monitor, and evaluate services to all subpopulations, including, but not limited to the ongoing special conditions that require a course of treatment or regular care monitoring, type of disability or chronic condition, race, ethnicity, gender, and age. A heath risk assessment shall be conducted and consist of the following minimum components:

  • Total cholesterol level;
  • HDL cholesterol level;
  • LDL cholesterol level;
  • TC/HDL ratio;
  • Triglycerides;
  • Glucose level;
  • Blood pressure check;
  • Waist circumference measurement;
  • Height measurement;
  • BMI calculation;
  • Depression screening;
  • Identification of allergy history;
  • Medication use discussion;
  • Complete age-appropriate EPSDT screenings.

Information collected shall also include demographic information and current health and behavioral health status to determine the need for care management, behavioral health services, or any other health or community services.

  1. Ombudsman (Function) Requirements
None specified.
  1. Quality-Related Financial Incentives
The state has a P4P program. During the first contract year, 6 performance measures are selected to measure the MCO's performance during implementation and the transition of members to the MCO. 3% of the total capitation payments are held back for the purpose of incentive payments to MCOs meeting the higher levels of performance. These performance standards require MCOs to exceed the minimum performance standard required for contract compliance and incentivize the MCOs to perform at a higher level in 6 areas determined by the state to be critical for successful integration of members into the new program. The year 1 operational measures are under the following domains:
  • Timely claims processing;
  • Encounter data submission;
  • Credentialing;
  • Grievances;
  • Appeals;
  • Customer Service.

Different measures from service data are used for years 2 and 3. MCOs who believe they can exceed the acceptable benchmark standard will be provided an opportunity to create and present additional performance targets and appropriate incentives. The state hopes to add measures which focus on patient outcomes, health and functional status. The state is particularly interested in measures which address smoking cessation and obesity rates. Any plan for additional incentives must be submitted by the MCO and the state reserves the right to accept, reject, or modify any additional incentive plan proposed by an MCO.

Measures related to the HCBS waiver for individuals with IDD will be developed by the state with MCO input and will be allowed to have an additional year of benchmarking.

  1. Experience of Care/ Satisfaction Feedback Requirements
None specified.
  1. LTSS Quality Review
Quarterly report on long-term care service providers.

Monthly institutional discharge reports (including those discharged from NFs).

Monthly service authorizations, service denials, and pending service authorizations (by program as specified by the state).

Monthly utilization of services by service type and average service utilization (by program as specified by the state).

ASAM = American Society of Addiction Medicine
BMI = body mass index
CI = critical incident
CMS = Centers for Medicare and Medicaid Services
DD = developmental disability

EPSDT = Early and Periodic Screening, Diagnosis, and Treatment Program
EQRO = external quality review organization
ER = emergency room
EVV = electronic visit verification
FE = frail elderly

HCBS = home and community-based services
HDL = high-density lipoprotein
HEDIS = Health Effectiveness Data and Information Set
IDD = intellectual and developmental disabilities
IT = information technology

KCPC = Kansas Client Placement Criteria
KDHE = Kansas Department of Health and Environment
LDL = low-density lipoprotein
LOC = level of care
LTSS = long-term services and supports

MCO = managed care organization
MH = mental health
NF = nursing facility
NOMS = National Outcome Measurement System
P4P = pay-for-performance

PCP = primary care provider/physician
PD = physical disability
PIP = performance improvement project
POC = plan of care
QM = quality management

RFP = request for proposal
SA = substance abuse
SED = serious emotional disturbance
SPMI = serious and persistent mental illness
TBI = traumatic brain injury

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